Provider Demographics
NPI:1124205877
Name:KNIGHT, KIMBERLY ANN (MACOM, LAC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2104
Mailing Address - Country:US
Mailing Address - Phone:503-395-8261
Mailing Address - Fax:
Practice Address - Street 1:3615 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2104
Practice Address - Country:US
Practice Address - Phone:503-200-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01163171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist